MEDICARE: ACTIVELIFE MEDICAL SUPPLIES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1265731509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVELIFE MEDICAL SUPPLIES LLC

Provider Business Mailing Address
First Line	:	4152 W ARMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-3694
Country	:	US
Telephone Number	:	773-930-4271
Fax Number	:	773-930-4275

Provider Business Practice Location Address
First Line	:	4152 W ARMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-3694
Country	:	US
Telephone Number	:	773-930-9271
Fax Number	:	773-930-4275

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MR. MARIO ROMANO
Credential	:	C. PED
Telephone Number	:	773-699-2599

Provider Enumeration Date	:	03/25/2011
Last Update Date	:	10/07/2022

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